What is the recommended treatment approach for a patient with melanoplakia, particularly those with a history of smoking?

Treatment of Melanoplakia

Critical Clarification: Melanoplakia vs. Melanoma

Melanoplakia is NOT melanoma and requires a fundamentally different treatment approach. Melanoplakia refers to pigmented oral mucosal lesions (oral melanotic macules, physiologic pigmentation, or melanoplakia), which are benign pigmented patches in the oral cavity 1. These must be distinguished from oral malignant melanoma, which is an aggressive cancer with poor prognosis 1, 2.

Initial Management: Diagnosis First

All pigmented oral cavity lesions should be viewed with suspicion and require biopsy when the clinical diagnosis is uncertain 1. This is critical because:

• Oral malignant melanoma often goes unrecognized for months or years, presenting as pigmented macules and plaques 1
• Early detection is the only way to improve survival in oral malignant melanoma due to its dismal prognosis 2
• Delayed recognition by both patients and physicians contributes to poor outcomes 1

Treatment Algorithm for Melanoplakia (Benign Pigmented Lesions)

If Biopsy Confirms Benign Melanoplakia:

Observation without intervention is the appropriate management approach 3. Benign oral pigmented lesions including:

• Oral melanotic macules
• Physiologic pigmentation
• Amalgam tattoos

These do not require surgical excision unless there are concerning features suggesting malignant transformation 1.

If Biopsy Shows Oral Malignant Melanoma:

Prompt aggressive surgical treatment with wide excision is essential 1. This represents a completely different disease entity requiring oncologic management similar to cutaneous melanoma.

Special Consideration: Smoking History

For patients with smoking history presenting with oral pigmented lesions, heightened vigilance is warranted because:

• Smoking is a risk factor for oral cavity malignancies
• Non-homogeneous pigmented lesions carry higher malignant potential 4
• Any suspicious features warrant immediate biopsy rather than observation 1, 2

Key Clinical Pitfalls to Avoid

Never assume a pigmented oral lesion is benign without histologic confirmation 1, 2. The differential diagnosis includes:

• Benign melanotic macules
• Amalgam tattoos
• Oral melanoacanthoma
• Kaposi's sarcoma
• Oral malignant melanoma (the most critical to exclude) 1

Do not delay biopsy in patients with:

• New or changing pigmented lesions
• Non-homogeneous appearance
• Lesions on high-risk sites (palate, gingiva)
• History of tobacco use 4, 1